Increasing Breast and Cervical Cancer Screening in Michigan July 15, 2016 Northwest Michigan Health Services, Inc.

Cancer Screening Disparities Michigan cancer screening rates: Cervical cancer screening (18 and over) = 77.3 Breast cancer screening (40 and over) =74.9 Mammogram in the past 2 years What are your breast and cervical cancer screening rates? How does that compare to the state rate?

Cancer Screening Disparities in Michigan Screening by Educational Attainment: Source: Michigan Behavioral Risk Factor Survey – State level data Oceana County Education: Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates Breast Cancer Screening Cervical Cancer Screening Less than High school 65.1 70.1 College Graduate 81.3 83.3 Education (females only) five year estimates Less than High School 14.2% High school graduate 33.7% some college 35.5% College Graduate 16.5%

Cancer Screening Disparities in Michigan Screening by Income Level: Source: Michigan Behavioral Risk Factor Survey – State level data Oceana County Household Income: Source: U.S. Census Bureau, 2014 American Community Survey 5-year Estimates Breast Cancer Screening Cervical Cancer Screening Less than 10,000 44.2 66.6 $50,000 or more 82.1 80.4 Median Household Income (5 year estimates) Less than $10,000 6.7 % $10,000 - $14,999 7.6 % $15,000-$24,999 14.4% $25,000 - $34,999 $35,000 - $49,999 16.2% $50,000 or more 40.6%

Michigan’s Breast and Cervical Program First started paying for cancer screening services for low income women in 1990. Funded by the Center’s for Disease Control and Prevention (CDC) Reached a maximum of 30,000 women in 2013.

Affordable Care Act Marketplace (ACA) and Healthy Michigan Plan (HMP) provided the opportunity for low-income women to have access to insurance. The need to pay for cancer screening services decreased Data demonstrates that access to insurance is not the only barrier to completing cancer screening services Need programming to increase cancer screening in Michigan’s low income insured population.

Cancer Screening Rates Healthy Michigan Plan Initial data from Healthy Michigan Plan (13 health plans) indicate screening rates below the state average: Over the 16 month period (4/2014 to 8/2015): Breast Cancer Screening rates averaged < 4%/month Cervical Cancer Screening rates averaged < 3% month Possible reasons for low screening rates in the newly insured: Both provider and patient are focused on urgent health issues first Difficulty accessing health system Lack of understanding of the importance of screening

Program Goal Assure low-income women receive timely access to needed breast and/or cervical cancer services.

What is the BCCCNP? Two Services: Caseload Services –acts as a “insurance company” and pays for breast and cervical cancer screening and diagnostic services for uninsured or underinsured women. Navigation Only Services – provides reimbursement for patient navigation to insured women to address barriers to breast and cervical screening. Why two service lines? 1. The women served by BCCCNP in the past, who are now insured, no longer have the support of BCCCNP agencies May not know how to use new insurance May not complete screening without BCCCNP support 2. Population Health - with less demand for caseload services, there are resources to increase screening services in the low income insured population.

Northwest Michigan Health Services, Inc. Navigation-Only Services: Provide payment to providers for navigating patients who are in need of but are not completing breast and/or cervical cancer screening. NOT for women who simply call and schedule annual screening and complete it without additional assistance. AIMED at finding women who have never been screened or who need an additional intervention in order to complete cancer screening.

Northwest Michigan Health Services, Inc. Providers have limited time to provide education on preventative health. Intent of this project is to provide funding to offices to enable outreach and education to practice patients to facilitate breast and cervical cancer screening.

Eligibility Criteria for Navigation- Only Services Be between the ages of 40 and 64 Income < 250% Federal Poverty Level* Income criteria set by federal law- must document woman’s verbal statement of income; no written proof required INSURED Requires breast/cervical cancer-related services ONLY Pap test, Mammogram, and/or follow-up services for abnormal test result **CDC changed policy regarding program eligibility to serve insured women - Impact of ACA/Medicaid Expansion shifted program focus - Population health cancer screening of low-income women is now becoming a program priority. Rationale for asking income is program services or resources (i.e. fuel cards) can only be offered to low-income women (< 250% FPL) per federal law Underinsured women (meeting income guidelines) can be offered assistance to pay for diagnostic services (if needed) if a breast or cervical abnormality is found but a high-deductible must be paid prior to the woman receiving the service.

Why use Navigation?

Navigation Works 1964-1986 1995-2000 Stage 0 0% 12% Stage I 6% 29% Stage II 45% 38% Stage III 39% 14% Stage IV 10% 7% 1964-1986 the 5 year survival rate at the Harlem Hospital center = 39 % (60% for white women) 1995-2000 the 5 year survival rate at Harlem Hospital = 70% Stage O and 1 moved from 6% to 41% Stage 3 and 4 moved from 49% to 21%

Navigation Works Increased Screening Rates Earlier diagnosis Stage 0 diagnosis went from 12.4% to 25.8% Stage IV diagnosis when from 16.7% to 9.4% Gabram et. al. (2008) Diagnostic resolution 90% of navigated Hispanic women followed through to diagnostic resolution compared to 66% of non-navigated women Ell et.al. (2007) Increased Screening Rates The cervical cancer screening rate increased from 17% to 83% in Korean women after the introduction of cervical cancer education and bilingual patient navigation. Fang et. al. (2007)

Patient Navigation

How can Navigation Help? Is fear the reason she is not being screened? Does she understand how cancer screening helps? Are there family care or transportation issues? Have you looked for appointment times that work with HER schedule?

What is a Root Cause? Symptom = Above the surface, obvious Root cause= Below the surface, not obvious The word “root” refers to underlying causes, rarely one cause.

Root Causes When using “5 Whys?” ask the following . . . Do you think this is the root cause? Should we ask “Why” again? If you address the root cause will the problem be permanently fixed?

Navigation Examples Education Brainstorming around or assistance with: Providing information on the importance of screening, types of screening tests, and/or addresses fear of cancer or cancer screening. Brainstorming around or assistance with: Transportation, child care, elder care Follow-up on “no-shows” or lack of follow-through on mammogram or diagnostics Asking about work schedules and how flexibility in scheduling will promote screening completion Interpreter services Assistance with completing forms or understanding written materials

Patient Navigation Team Navigation is a process not an individual: Navigation services can be provided by one person or shared by several individuals. Patient Navigator does not need to be a health care professional to provide non-clinical services. Unmet needs are identified and then split based on the skills of each team member.

Navigation in Provider Offices Improves provider screening rates Promotes earlier screening and successful diagnostic resolution Decreases no-shows Navigation payment ($60) per woman navigated for breast and cervical cancer screening / diagnostics.

Navigation in Provider Offices Identify individual barriers/problems that impede access to obtaining breast/cervical cancer screening, diagnosis and/or treatment services Provide individualized support and assistance to overcome barriers/problems Document your work

Who Do We Navigate? To be eligible a woman must: Meet age, income, insurance eligibility criteria AND Is in need of breast / cervical cancer screening or diagnostic assistance AND Requires education/assistance/resources to obtain needed breast/cervical cancer services Is willing to complete breast /cervical cancer screening

When is Navigation Complete? Has at least 2 (TWO) encounters with designated office staff via phone, email, or in-person Completes breast and/or cervical cancer screening and any required diagnostics.

Key Components Client is eligible (age and income) At least ONE Barrier/Problem is identified A solution is put in place for each identified barrier/problem. Client receives needed breast or cervical screening and/or diagnostic services. This is a different way of saying slide 20, I can do this one too

How do I know if I resolved a barrier? Did you provide a specific intervention to address an identified need? i.e. problem solve appoint times, provide gas card Did you provide education to a woman on cancer, cancer screening, the use of insurance…? Did you spend time helping her brainstorm family care, work barriers….? Did you spend time helping her address specific health system barriers?

Patient Navigation Forms

Information Needed to Document Navigation Services Age/Income Breast/Cervical screening services needed Barriers/problems the woman may have to receiving services Assistance provided by navigator to overcome barriers/problems Types and dates of services received

Navigation-Only Clients What counts as a SECOND ENCOUNTER? Any of the following will count as a second encounter: In-person visit Telephone contact Email or other written contact from the patient Voicemail message left for the navigator by the woman in response to a navigator voicemail message No problem

Form #1 – Intake Form

Navigation Intake Form Documents: Eligibility Client Information Breast and/or cervical services required by the client Barriers that may interfere with obtaining these services

Intake Form Encounter # 1 Date - Type of Encounter – When did you first talk to this client about cancer screening and assess the reasons they are not completing screening Write date Type of Encounter – How did you have this conversation? Face-to-Face? By phone? Check the appropriate box

2016 Federal Poverty Level (FPL) Guidelines Size of Family Unit Poverty Guideline 250% of Poverty 138% of Poverty 1 $11,880.00 $29,700.00 $16,394.40 2 $16,020.00 $40,050.00 $22,107.60 3 $20,160.00 $50,400.00 $27,820.80 4 $24,300.00 $60,750.00 $33,534.00 5 $28,440.00 $71,100.00 $39,247.20 6 $32,580.00 $81,450.00 $44,960.40 7 $36,730.00 $91,825.00 $50,687.40 8 $40,890.00 $102,225.00 $56,428.20 Each Additional Member (Beyond 8) $4,160.00 $10,400.00 $5,740.80

Intake Form: Client Eligibility Record reported income and # people in household Verbal declaration by client is accepted (no proof of income required) If the household income is above 250% of the Federal Poverty Level for the family/unit the BCCCNP program will not be able to provide payment for navigation. Note: Numbers indicate 2016 FPL guidelines

Intake Form: Client Information Starred (*) items must be completed on form Address, phone number & email address is optional We are required to collect race/ethnicity data. However the client has the right to refuse to provide that information.

Client Verbal Acknowledgement “Based on the information that you are telling me, here is what I can do for you.” Explain navigation services that can be provided to the client based on your assessment and confidentiality will be maintained.   “I am/will make suggestions for you based on the information you give me.  If, for some reason, that information is not correct or if your situation changes, that may affect what I told you.  In that case, please call me and we will talk about this further.” Document “Yes” in the Client Verbal Acknowledgement for Services on the Michigan Breast and Cervical Navigation Services Outreach Navigation Intake Form. Written Informed Consent Not Required

Intake Form: Client Information Client Verbal Acknowledgement Check “Yes” that client has agreed for assistance in obtaining breast/cervical services If the client does not give verbal acknowledgment, the BCCCNP program will not be able to provide payment for navigation.

Client Assessment: Services Required Screening Services Received in Past Year Mark services received in the past year For unknown dates - approximate closest date If no services provide – check “none” Screening/Diagnostic Services Needed Check appropriate services needed *Note: If only diagnostic services are needed explain reason for diagnostic services.

Intake Form: Barrier Assessment Check identified barriers For each barrier checked, record briefly in comments how you will address the barrier Prior to ending the contact/call with the client obtain the next date that you will contact her and document it on the enrollment form. Sign and date the form. (List of navigator names needed)

Form #2 – Encounter From

IHP Patient Navigation Encounter Form Documents: Breast and/or cervical cancer services received by the client Referrals/Resources provided to the client ______________________ You can complete a separate form for each encounter -or- You may summarize client contacts on one form as long as the navigation process can be clearly understood.

Encounter Form: Navigation Services Completed Document the following: Dates of screening/diagnostic services received Referrals/Resources provided to client

Encounter Form: Navigation Status Navigation status (ongoing): Do you need to contact the client again? – Yes, identify when you will contact the patient. Provide brief comments on current encounter

Encounter Form: Navigation Status Navigation status (complete): Do you need to contact the client again? – No, all breast/cervical screening/diagnostic services are complete. Provide brief comments on current encounter. Sign and date encounter form Fax complete forms to NMHSI.

Documentation When you document your navigation you need to tell us what you did: Keep it brief, we don’t need to know specific deals of the woman’s life Do provide us enough information that we know what the barrier was AND how YOU resolved it. Completed service – the woman MUST need and complete cancer screening and/or diagnostic services

Options for the Uninsured and Underinsured

BCCCNP Services Caseload Services Navigation-Only Services BCCCNP acts as a “insurance company” and pays for breast and cervical cancer screening and diagnostic services with contracted providers for uninsured or underinsured women Navigation-Only Services BCCCNP navigator ASSISTS insured women with overcoming barriers/resolving problems that may prevent them from receiving breast and cervical services.

Caseload Services Program Eligibility Age - 40-64 and requiring breast/cervical screening/diagnostic services 21–39 and referred to the program with an abnormal screening Pap test OR clinical breast exam which requires breast/cervical diagnostic services   Residency and Citizenship Status - Current Michigan Resident Can include non-citizens or migrant workers Insurance Status  Uninsured women / Underinsured women (women with high deductibles) Insured women – Navigation Service line only Income - < 250% Federal Poverty Level

BCCCNP Caseload Services BCCCNP will pay for breast/cervical cancer screening and diagnostic services for those who are do not have insurance or who need diagnostics but face a high deductible Defined as: “I cannot afford that amount” Will count as navigation (you resolved an insurance/financial barrier)

BCCCNP Caseload Services IMPORTANT: You must refer these women to the Health Departments listed below for these services to be covered by BCCCNP For women in Manistee & Oceana Counties: refer to Katie Gunderson at DHD #10 (phone: 231-876-3826) For women in Grand Traverse County: refer to Joy Klooster at Health Department of Northwest MI (phone: 231-547-7677)

Case Scenarios

Case Scenario # 1 Mary has Marketplace Insurance. When you talk to her about cancer screening she states she is not sure what her insurance company will cover. She states she cannot afford to pay extra money right now. She also states that she does not have sick time and may be fired if she takes time off of work. Barriers identified? What can be done?

#1 - Intake Form

#1- Intake Form (Continued)

#2 – Encounter Form

#2 – Encounter Form (Continued)

Case Scenario # 2 Phone call from Angela, who is very upset stating she found a lump on her breast and is afraid that it might be cancer. Her older sister was diagnosed with breast cancer 2 years ago. She has not had a mammogram. Has enrolled for insurance through the Marketplace but not sure what is covered and has no money to pay for testing. What interventions do you see? Barriers No health provider Concerns regarding possible abn screening result.cancer Insurance issues

#1 – Intake Form

#2 – Encounter Form

#2 – Encounter Form (Continued)

Case Scenario #3 Gwen, age 50, is in the office for a routine follow-up related to her high blood pressure. You note on her chart that there is no record of breast of cervical cancer screening in the past 5 years. You ask her if she has completed either and she replies she has not. You assess her knowledge of cancer screening and provide education on why and how this screening is done. You ask Gwen if she is willing to set an appointment to start the screening process. What was the barrier?

#1 – Intake Form

Navigation may take Persistence - Form 2 You call Gwen on the agreed upon contact date and determine that she has not followed through with setting up screening appointments.

Follow-up Diagnostics –Form 2 again You call Gwen and learn her PAP was positive and she needs diagnostic follow-up.

Navigate until no further services are needed Note: This is a Third – Encounter Form

Case Scenario #4 Vicki , age 45, is a new patient to you with a Healthy Michigan Plan. You have not seen Vicki since her initial visit. At that time you identified that Vicki had a positive mammogram through a free screening program but she did not follow-up on diagnostics. Vicki no-showed for the diagnostic mammogram you scheduled for her. What is your next steps?

Form #1 – Before she now-showed

Form #2 – Address Barriers that led to no-show

2nd Encounter Form – Services Complete

Eligibility Review Eligible Not- Eligible Contact MDHHS Age 40 to 64 X Under 40 in need of diagnostics 65 and over Income < 250% of poverty Income over 250% of poverty Undocumented / non-citizen

Which Service Line - Review Navigation Refer to BCCCNP Insured X Uninsured Underinsured No insurance refer to BCCCNP – her breast or cervical cancer screening and any necessary diagnostic services will be covered Underinsured refer to BCCCNP as needed for diagnostics– some women face high deductibles or co-pays You may additionally qualify for navigation payments if you assisted in resolving barrier

BCCCNP Funding for Providing Navigation Services MDHHS will fund your agency the following amounts in a lump sum payment From July 1 – September 30, 2016: $1000 “Administrative fees” Use these funds to offset costs in establishing the navigation program at your sites and initially paying for some navigation services of clients MDHHS will fund the agency with $18,000 in one lump sum payment. $6,000 “Administrative fees” Identifying clinic sites to participate Training the clinic sites – with MDHHS assistance, if needed Collecting all navigation forms from the clinics Reviewing all forms for completeness Sending all forms to MDHHS $12,000 = $60 per woman navigated (200 women = target) Payment to your sites/clinics will be internally among your agency and the clinics

BCCCNP Funding for Providing Navigation Services From October 1, 2016 – September 30, 2017: $12,500 $5000 – “Administrative fees” Identifying clinic sites to participate Training the clinic sites – with MDHHS assistance, if needed Collecting all navigation forms from the clinics Reviewing all forms for completeness Sending all forms to MDHHS $7,500 = $60 per woman navigated (125 women = target) Payment to your sites/clinics will be internally among your agency and the clinics

Frequently Asked Questions 1. Who do I call with questions about completing the form or if a woman qualifies for BCCC navigation services? Tory Doney - doneyt@michigan.gov or 517-335-8854. Who do I call if I identify a woman who needs help paying for breast of cervical screening or diagnostic services: Manistee or Oceana Counties – District Health Department #10 Phone – 231-876-3826 Grand Traverse County – Health Department of Northwest Michigan Phone – 231-547-7677 Who do I call to learn more about navigation in my practice? Debbie Webster – websterd1@michigan.gov

Frequently Asked Questions 4. Does the program provide support for women diagnosed with breast or cervical cancer? YES!! Income eligible women, (insured, uninsured, and underinsured) may be eligible to enroll in a special Medicaid program through the BCCCNP. Women currently enrolled in HMP can transfer into the BCCCNP Medicaid program at any point during their treatment where they will incur NO co-pays! All other insured women (non-Medicaid) MUST be newly diagnosed with cancer in order to qualify

Frequently Asked Questions Who do I contact about assistance for breast or cervical cancer treatment for my patient? E.J. Siegl - siegle@michigan.gov or 517-335-8814 6. Where do I find forms and important contact information for this program? Northwest Michigan Health Services, Inc. Patient Navigation page is found at: http://www.michigancancer.org/bcccp/PtNav/NMHSI.html

Questions?